Primary Antireflux Surgery Research Articles

Safety and efficacy of Roux-en-Y gastric bypass as revisional bariatric surgery after failed anti-reflux surgery: a systematic review.

This systematic review evaluates the safety and efficacy of Roux-en-Y gastric bypass (RYGB) on weight loss and anti-reflux outcomes when used as a revisional bariatric surgical procedure after failed anti-reflux surgery. A systematic literature search next to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed for articles published by 30 Mar 2022. After examining 416 papers, 23 studies were included (n = 874 patients). Primary anti-reflux surgery included mainly Nissen fundoplication (16 studies). Reasons for revisional surgery included predominantly gastroesophageal reflux disease (GERD) (reported by 18 studies), obesity (reported by 6 studies), and hiatal hernia (reported by 6 studies). Interval to surgical revision was 5.58 ± 2.46 years (range, 1.5-9.4 yr). Upper endoscopy at revision was performed for all patients; esophageal manometry and pH monitoring were reported in 6 and 4 studies, respectively. Mean body mass index (BMI) at revision was 37.56 ± 5.02 kg/m2 (range, 31.4-44 kg/m2). Mean excess weight loss was 69.74% reported by 12 studies. Delta BMI reported by 7 studies was 10.41 kg/m2. The rate of perioperative complications was 16.7%, including mostly stenosis, leakage, ventral hernia, and small bowel obstruction. Mean improvement rate of GERD was 92.62% with a mean follow-up of 25.64 ± 16.59 months reported in 20 studies. RYGB seems to be an efficient surgical treatment option in failed anti-reflux procedures, but should be performed in experienced centers for selected patients, since the rate of perioperative and long-term complications must be minimized. Cooperation between bariatric and reflux surgeons is essential to offer patients with obesity and GERD the best long-term outcome.

Management Strategies for Dysphagia Complicating Laparoscopic Nissen Fundoplication, Systematic Review

Abstract Background Gastroesophageal reflux disease (GERD) is a common global disorder. Manifestations of the disease range from occasional episodes of heartburn and regurgitation to the more serious complications of stricture and Barrett’s esophagus. Most patients manage their symptoms with a combination of dietary and lifestyle modifications and overthe-counter or prescription medications. Aim of the Work This study aims to assess the incidence, etiology, diagnosis and management strategies for dysphagia following laparoscopic Nissen fundoplication. Patients and Methods Published studies discussing dysphagia as a complication of laparoscopic Nissen fundoplication. Patients developed dysphagia after laparoscopic Nissen fundoplication as primary anti-reflux surgery, the type of intervention was laparoscopic Nissen fundoplication. Types of outcome measures: Incidence, etiology, diagnosis and management strategies for dysphagia following laparoscopic Nissen fundoplication. The published English-language literature will be searched in the databases PUBMED, EMBASE, Google Scholar, Science direct and Cochrane Register of Controlled Trails (The Cochrane Library). The search terms will be employed: “Nissen fundoplication” “early dysphagia” “ late dysphagia”. Results In our present systematic review, we observed that the incidence of post-operative dysphagia after laparoscopic Nissen fundoplication among the included studies ranged from 8.2% to 42.8% with average percent of 33.2%. Transient postoperative dysphagia was more prominent in most of the included studies with average 52.8%, while persistent dysphagia was in reported in 47.2% of cases. In the present systematic review and meta-analysis, 707 of patients who developed postoperative dysphagia responded to conservative management with percent of 92.4%, while the remaining 58 patients required more invasive modalities. Endoscopic dilatation was performed in 54 (7.1%) of patients, while the remaining 4 patients (0.5%) were indicated for surgical reintervention. Conclusion Post laparoscopic Nissen fundoplication dysphagia is one of the most common complications, most cases present with a transient course that require no more than conservative management. In few conditions, more invasive procedures maybe required to control that condition.

Pre-existing hiatal mesh increases morbidity during and after revisional antireflux surgery: A retrospective multicenter study

BackgroundRevisional antireflux surgery, including hiatus hernia repair, is increasingly common. Mesh-augmented hiatal closure at the time of index operation is controversial but commonly performed. Although a meta-analysis of randomized data has demonstrated no additional benefit of routine mesh placement, it is unclear whether this practice results in harm, particularly at the time of revisional antireflux surgery. We determined whether pre-existing mesh at the hiatus increases morbidity during and after revisional antireflux surgery. MethodsAnalysis of prospectively-maintained databases of all elective revisional antireflux surgery cases in 36 hospitals across Australia took place over 10 years. Intraoperative and postoperative outcomes of patients with and without prior hiatal mesh were compared. Propensity score-matched analysis was used to validate primary findings. ResultsA total of 346 revisional cases (35 with pre-existing mesh) were analyzed. The 2 groups had comparable baseline characteristics. In total, 77 (22.2%) patients had 148 intraoperative adverse events. Pre-existing mesh was associated with a higher risk of intraoperative complications (48.6% vs 22.5%, odds ratio 3.25, 95% confidence interval 1.63–6.38, P = .002), secondary to bleeding, and lacerations to pleura, lung, and liver. Overall, 63 (18.2%) patients developed postoperative complications. Pre-existing mesh was associated with increased postoperative morbidity (37.1% vs 16.1%, odds ratio 3.09, 95% confidence interval 1.50–6.43, P = .005), particularly due to bleeding and respiratory complications. Importantly, pre-existing mesh independently predicted the occurrence of intraoperative and postoperative complications. ConclusionPrior hiatal mesh significantly increases morbidity during and after revisional antireflux surgery. Given that revisional surgery is increasingly being performed, our findings discourage routine mesh use during primary antireflux surgery.

Surgical Perspective on Evaluation and Management of Recurrent Reflux After Primary Antireflux Surgery

While fundoplication as a treatment for gastroesophageal reflux disease (GERD) has been largely successful, the rise in reflux cases refractory to initial surgery presents a unique challenge in the search for more durable symptom relief. In addition to principles pertaining to medical management and reoperation, this article discusses several nuances to consider in the careful evaluation of recalcitrant GERD post-fundoplication to optimize long-term success after revisional antireflux surgery from a surgical perspective.

How effective is laparoscopic redo-antireflux surgery?

The failure-rate after primary antireflux surgery ranges from 3 to 30%. Reasons for failures are multifactorial. The aim of this study is to gain insight into the complex reasons for, and management of, failure after antireflux surgery. Patients were selected for redo-surgery after a diagnostic workup consisting of history and physical examination, upper gastrointestinal endoscopy, quality-of-life assessment, screening for somatoform disorders, esophageal manometry, 24-hour-pH-impedance monitoring, and selective radiographic studies such as Barium-sandwich for esophageal passage and delayed gastric emptying. Perioperative and follow-up data were compiled between 2004 and 2017. In total, 578 datasets were analyzed. The patient cohort undergoing a first redo-procedure (n = 401) consisted of 36 patients after in-house primary LF and 365 external referrals (mean age: 62.1years [25-87]; mean BMI 26 [20-34]). The majority of patients underwent a repeated total or partial laparoscopic fundoplication. Major reasons for failure were migration and insufficient mobilization during the primary operation. With each increasing number of required redo-operations, the complexity of the redo-procedure itself increased, follow-up quality-of-life decreased (GIQLI: 106; 101; and 100), and complication rate increased (intraoperative: 6,4-10%; postoperative: 4,5-19%/first to third redo). After three redo-operations, resections were frequently necessary (morbidity: 42%). Providing a careful patient selection, primary redo-antireflux procedures have proven to be highly successful. It is often the final chance for a satisfying result may be achieved upon performing a second redo-procedure. A third revision may solve critical problems, such as severe pain and/or inadequate nutritional intake. When resection is required, quality of life cannot be entirely normalized.

802 PERIOPERATIVE AND SHORT-TERM OUTCOMES FOR PRIMARY ANTIREFLUX SURGERY: FUNDOPLICATION VS. RNY RECONSTRUCTION

Abstract Laparoscopic fundoplication is the gold standard for treatment of gastroesophageal reflux disease (GERD); however, RNY reconstruction may be an alternative option in patients with complex pathophysiology and other risk factors. This study aimed to compare perioperative and short-term outcomes between primary fundoplication and RNY reconstruction. Methods After IRB approval, a prospectively maintained esophageal surgery database was retrospectively reviewed to identify patients who underwent primary fundoplication or RNY reconstruction from September 2016 to July 2020. We retrieved perioperative outcomes (operative time, length of hospital stay, intraoperative and postoperative complications) along with GERD-Health-Related Quality of Life (HRQL) scores at annual follow-up. Results During the study period, 226 patients underwent surgery (fundoplication: 210; RNY: 16). The most common indication for RNY was severe esophageal dysmotility or morbid obesity. There was only one conversion to open surgery due to adhesions (fundoplication group). The operative time, length of hospital stay, and ICU stay were significantly lower in the fundoplication group. Rates of intraoperative (fundoplication: 3% vs RNY: 0) and postoperative complications (Clavien-Dindo ≥II) (fundoplication: 3% vs RNY: 6%) were not significantly different between groups. Both groups had a significant and similar improvement of GERD-HRQL scores 1 year after surgery (Table 1). Conclusion Primary antireflux surgery is associated with low perioperative morbidity and excellent short-term outcomes. RNY reconstruction and fundoplication have similar outcomes. More liberal use of RNY reconstruction as the primary antireflux surgery in patients at high risk of failure with fundoplication should be explored.

801 EXOSOMES CONTAINING LUNG SELF-ANTIGENS COLLAGEN-V AND Kα1-TUBULIN ARE PREVALENT IN PATIENTS WITH SYMPTOMATIC GASTROESOPHAGEAL REFLUX: RESULTS FROM A PILOT STUDY

Abstract Gastroesophageal reflux disease (GERD) has been associated with aspiration-induced pulmonary injury; however, good clinical or laboratory markers are not available. Increased serum levels of exosomes containing normally sequestered primary lung self-antigens (collagen-V, Kα1-tubulin) have been associated with lung injury in the lung transplant population. The aim of this pilot study was to assess the prevalence of exosomes containing collagen-V and/or Kα1-tubulin in patients with severe GERD. Methods After IRB approval, the institutional biobank database was queried to identify non-lung transplant patients who underwent primary anti-reflux surgery (ARS) from 2019 to 2020. Serum samples were retrieved from the repository. Exosome pellets were isolated using the Invitrogen® kit using the manufacturer’s protocol. The size of exosomes in the pellet was confirmed using NanoSight. Western blot of the exosomes was used to isolate and quantify collagen-V and Kα1-tubulin, using CD-9 as the standard. A ratio > 1 was considered abnormal. Results Ten patients (6 females) with a median (IQR) age of 53 (42, 63) years were included in this study. All patients had symptomatic GERD as an indication for ARS. Five patients (50%) had exosomes containing abnormal levels of collagen-V and/or Kα1-tubulin (Figure 1). There was a mean 2.9- and 8.2-fold increase in collagen-V and Kα1-tubulin, respectively. Conclusion Humoral factors associated with lung injury are highly prevalent in patients undergoing elective ARS for GERD. This suggests that detection of exosomes containing lung self-antigens collagen-V and Kα1-tubulin could be useful as a biomarker of GERD-induced lung injury.

Reconstructive stage of surgery after cardiectomy

There is no consensus regarding the operation of choice for pathological changes in the proximal stomach, distal esophagus and the area of the cardio-esophageal junction to the present day. In addition to malignancy and peptic ulcer disease, a refractory course of gastroesophageal reflux disease (GERD) and the absence of any effect from primary antireflux surgery may be an indication for performing cardiectomy with reconstruction. To make a choice of the surgical treatment for pathologies of the distal esophagus and proximal stomach method, it is necessary to compare the efficiency and safety profiles of these techniques in many parameters. The main indicators of the effectiveness of reconstructive operations after cardiectomy, are the frequency and severity of a large group of functional disorders characterized as “dumping syndrome” or “postgastrectomy syndrome”. A huge number of different types of anastomosis after cardiectomy has been proposed and studied. Nevertheless, an an objective evaluation of the results of these anastomosis types’ use, indicates that the hopes placed on them did not come true in most cases. It indicates insufficient coverage of this problem in scientific literature, despite the continuing interest of surgeons.

The impact of pneumoperitoneum on esophagogastric junction distensibility during anti-reflux surgery.

We aimed to quantify the contribution of pneumoperitoneum on compliance of the esophagogastric junction (EGJ) during anti-reflux surgery. Compliance of the EGJ is reduced with anti-reflux surgery. EndoFLIP® planimetry can be used to assess dynamic changes of EGJ compliance intraoperatively. It is unclear how pneumoperitoneum impacts intraoperative measurements by EndoFLIP® and the implications thereof on validity of the results. Therefore, determining variability in EndoFLIP® measurements based on pneumoperitoneum is warranted to establish guidelines to interpret clinical outcomes. Primary anti-reflux surgery was performed on 39 consecutive patients with pathologic reflux. Intraoperative EGJ measurements including distensibility index (DI), cross-sectional area (CSA), and intrabag pressure were collected using EndoFLIP® at 0, 10, and 15mmHg of intraperitoneal pressure. Data were acquired pre-procedure, post-hiatal hernia repair, and post-LES augmentation with fundoplications. Patients underwent Nissen (13.2%), Toupet (68.4%), LINX (10.5%), or Hill-fundoplications (7.9%). There was no difference between 0 and 10mmHg of pneumoperitoneum in CSA, pressure, or DI measurements pre-procedure; however, there was a difference between 0 and 15mmHg in pressure (p = 0.016) and DI (p = 0.023) measurements. After LES augmentation, 10mmHg intraperitoneal pressure reduced DI, though the absolute difference is small (2.0 vs. 1.5 mm2/mmHg, p = 0.002). Pneumoperitoneum affected EGJ distensibility at 15mmHg, but not 10mmHg, of insufflation prior to anti-reflux procedures. After anti-reflux surgery, there was a significant variance between 0 and 10mmHg of pneumoperitoneum in pressure and distensibility. The change in pressure appears linear and needs to be considered if procedural modifications are performed based on intraoperative findings and when evaluating clinical outcomes.

Hospital volume of esophageal cancer surgery in relation to outcomes from primary anti-reflux surgery.

No previous study has sought to identify the effect of hospital volume of esophagectomy on anti-reflux surgery outcomes. The hypothesis under investigation was hospitals performing esophagectomies, particularly those of higher annual volume, have better outcomes from primary anti-reflux surgery. This population-based cohort study included adult individuals (≥18years) in Sweden receiving primary anti-reflux surgery for a recorded gastro-esophageal reflux disease in 1997-2010, with follow-up until 2013 The 'exposure' was hospital volume of esophagectomy, with hospitals conducting esophagectomies divided into 0, >0-1, >1-3 and ≥ 4 based on annual volume, and hospitals not conducting esophagectomies were the reference category. The outcomes were 30-day re-intervention and surgical re-intervention during the entire follow-up after anti-reflux surgery. Multivariable Cox regression provided hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for age, sex, comorbidity, type of anti-reflux surgery, and year of anti-reflux surgery. Among 10,959 participants having undergone primary anti-reflux surgery, the 30-day re-intervention rate was 1.1%, and the rate of surgical re-intervention during the entire follow-up was 6.8%. Compared with hospitals not performing esophagectomy, hospitals in the highest volume group of esophagectomy showed no decreased risks of 30-day re-intervention (HR = 1.46, 95% CI 0.89-2.39) or surgical re-intervention (HR = 1.21, 95%CI 0.91-1.60) during follow-up. Similarly, the intermediate hospital volume categories of esophageal cancer surgery had no decreased risk of surgical re-interventions after anti-reflux surgery. This study provides no evidence for centralization of primary anti-reflux surgery to centers for esophageal cancer surgery.

Quantifying Factors Essential to the Integrity of the Esophagogastric Junction During Antireflux Procedures

To quantify the contribution of key steps in antireflux surgery on compliance of the EGJ. The lower esophageal sphincter and crural diaphragm constitute the intrinsic and extrinsic sphincters of the EGJ, respectively. Interventions to treat reflux attempt to restore the integrity of the EGJ. However, there are limited data on the relative contribution of critical steps during antireflux procedures to the functional integrity of the EGJ. Primary antireflux surgery was performed on 100 consecutive patients with pathologic reflux. Intraoperative EGJ measurements including distensibility index (DI), cross-sectional area (CSA), and HPZ length were collected using EndoFLIP. Data was acquired pre-repair, post-diaphragmatic re-approximation with sub-diaphragmatic EGJ relocation, and post-sphincter augmentation. Patients underwent Nissen (45%), Toupet (44%), or LINX (11%). After diaphragmatic re-approximation, DI decreased by a median 0.77 mm2/mm Hg [95%-confidence interval (CI): -0.99, -0.58; P < 0.0001], CSA decreased 16.0 mm2 (95%-CI: -20.0, -8.0; P < 0.0001), whereas HPZ length increased 0.5 cm (95%-CI: 0.5, 1.0; P < 0.0001). After sphincter augmentation, DI decreased 0.14 mm2/mm Hg (95%-CI: -0.30, -0.04; P = 0.0005) and CSA decreased 5.0 mm2 (95%-CI: -10.0, 1.0; P = 0.0.0015), whereas HPZ length increased 0.5 cm (95%-CI: 0.50, 0.54; P < 0.0001). Diaphragmatic re-approximation had a higher percent contribution to distensibility (79% vs 21%), CSA (82% vs 18%), and HPZ (60% vs 40%) than sphincter augmentation. Dynamic intraoperative monitoring demonstrates that diaphragmatic re-approximation and sub-diaphragmatic relocation has a greater effect on EGJ compliance than sphincter augmentation. As such, antireflux procedures should address both for optimal improvement of EGJ physiology.

Reoperation after antireflux surgery: a population-based cohort study.

Antireflux surgery for gastro-oesophageal reflux disease (GORD) and/or hiatal hernia is effective. Between 10 and 20 per cent of patients undergo reoperation for recurrent symptoms. Most studies are undertaken in a single centre and possibly underestimate the rate of reoperation. The aim of this nationwide population-based cohort study was to investigate long-term reoperation rates after antireflux surgery. This study included patients who underwent antireflux surgery between 2000 and 2017 in Denmark, and were registered in the Danish nationwide health registries. Reoperation rates were calculated for 1, 5, 10 and 15 years after the primary antireflux operation for GORD and/or hiatal hernia. Duration of hospital stay, 30- and 90-day mortality and morbidity, and use of endoscopic pneumatic dilatation were assessed. This study included a total of 4258 antireflux procedures performed in 3717 patients. Some 3252 patients had only primary antireflux surgery and 465 patients underwent reoperation. The 1-, 5-, 10- and 15-year rates of repeat antireflux surgery were 3·1, 9·3, 11·7 and 12·8 per cent respectively. Thirty- and 90-day mortality rates were similar for primary surgery (0·4 and 0·6 per cent respectively) and reoperations. The complication rate was higher for repeat antireflux surgery (7·0 and 8·3 per cent at 30 and 90 days respectively) than primary operation (3·4 and 4·8 per cent). A total of 391 patients (10·5 per cent of all patients) underwent endoscopic dilatation after primary antireflux surgery, of whom 95 (24·3 per cent) had repeat antireflux surgery. In this population-based study in Denmark, the reoperation rate 15 years after antireflux surgery was 12·8 per cent. Reoperations were associated with more complications.

Reintervention After Antireflux Surgery for Gastroesophageal Reflux Disease in England.

After antireflux surgery, highly variable rates of recurrent gastroesophageal reflux disease (GERD) have been reported. To identify the occurrence and risk factors of recurrent GERD requiring surgical reintervention or medication. The Hospital Episode Statistics database was used to identify adults in England receiving primary antireflux surgery for GERD in 2000 to 2012 with follow-up through 2014, and the outcome was surgical reintervention. In a subset of participants, the Clinical Practice Research Datalink was additionally used to assess proton pump inhibitor therapy for at least 6 months (medical reintervention). Risk factors were assessed using multivariable Cox regression providing adjusted hazard ratios (HRs) with 95% confidence intervals (95% CIs). Among 22,377 patients who underwent primary antireflux surgery in the Hospital Episode Statistics dataset, 811 (3.6%) had surgical reintervention, with risk factors being age 41 to 60 years (HR = 1.22, 95% CI 1.03-1.44), female sex (HR = 1.5; 95% CI 1.3-1.74), white ethnicity (HR = 1.71, 95% CI 1.06-2.77), and low hospital annual volume of antireflux surgery (HR = 1.32, 95% CI 1.04-1.67). Among 2005 patients who underwent primary antireflux surgery in the Clinical Practice Research Datalink dataset, 189 (9.4%) had surgical reintervention and 1192 (59.5%) used proton pump inhibitor therapy, with risk factors for the combined outcome being age >60 years (HR = 2.38, 95% CI 1.81-3.13) and preoperative psychiatric morbidity (HR = 1.58, 95% CI 1.25-1.99). At least 3.6% of patients may require surgical reintervention and 59.5% medical therapy following antireflux surgery in England. The influence of patient characteristics and hospital volume highlights the need for patient selection and surgical experience in successful antireflux surgery.

Laparoscopic repeat surgery for gastro-oesophageal reflux disease: Results of the analyses of a cohort study of 117 patients from a multicenter experience.

Short and long-term outcomes after repeat anti-reflux surgery (RARS) are still debated and generally not considered as satisfying as after primary anti-reflux surgery (PARS). The aim of this study was to evaluate functional outcomes after RARS and risk factors associated to intra-operative and post-operative complications. This is a multicenter retrospective survey from four European laparoscopic centers. Patients who underwent elective RARS from January 2005 to October 2017 for dysphagia or for persistent reflux disease refractory to medical treatment were analyzed. Data on demographic characteristics, including type and timing of previous operations as well as intra-operative details (surgical technique, type of RARS, conversion to open surgery, prosthetic material placement) were collected. Patients who underwent operations in the emergency setting, interventions mixed with bariatric procedures and PARS performed in other surgical departments were not included in this study. Primary endpoint of this study was to evaluate risk factors associated with intraoperative and postoperative complications. Secondary endpoint was to evaluate clinical outcomes and to identify any possible correlation with clinical and surgical parameters. Among 1662 patients who underwent PARS, failure occurred in 174 (10.5%) patients. Repeat surgery was performed in 117 (7%) patients, after a mean time of 80 months (range 4-315). RARS was carried out laparoscopically in 88% of cases. Prosthetic mesh to reinforce hiatoplasty was used in 22.2% of patients. Intra-operative upper gastro-intestinal tract's injuries occurred in 6 (5.1%) patients. Perioperative mortality was nil and 13 (11.1%) patients experienced postoperative complications. Mean length of hospital stay was 9.6±6.4 days. Based on a multivariable analysis, age >70 years (OR 1.074, C.I.95% 1.018-1.133, p=0.008) and body mass index (BMI)<23 (OR 0.172, C.I.95% 0.052-0.568, p=0.004) were independently associated to postoperative complications. After a mean follow-up time of 36 months (range 6-107), 24 (20.5%) patients presented recurrent symptoms. Based on a multivariable analysis, early onset of dysphagia (OR 3.539, C.I.95% 1.254-9.990, p=0.017), open approach (OR 4.505, C.I.95% 1.314-15.442, p=0.016) and the use of prosthetic material (OR 2.790, C.I.95% 0.930-8.776, p=0.047) were significantly associated to good clinical outcomes. Repeat anti-reflux surgery is a safe and feasible procedure in high-volume centers, with acceptable perioperative outcomes. Long-term results are favorable with a success rate of almost 80%. Advanced age (>70 years) and low BMI (<23kg/m2) were factor predicting perioperative complications. The use of prosthesis for hiatoplasty was associated to better functional outcomes.

Laparoscopic fundoplication for refractory GERD: a procedure worth repeating if needed.

Laparoscopic fundoplication is the current gold standard for medically refractory gastroesophageal reflux disease. Over a 10-year period following surgery, 5-10% of primary laparoscopic fundoplication patients undergo reoperative surgery. Our objective was to compare the symptomatic outcomes and morbidity of primary and reoperative fundoplication procedures. This was a retrospective review of patients who underwent laparoscopic primary or reoperative fundoplication between 2011 and 2017. A single surgeon with a more than 10-year experience in reoperative foregut surgery performed all procedures. Patients in both groups completed the GERD health-related quality of life (GERD-HRQL) survey prior to surgery and postoperatively. Outcomes were reflected by the composite GERD-HRQL scores (0 to 50, with lower scores representing a better GERD-related quality of life), which were compared between groups postoperatively. Demographics, perioperative data, and complications were compared. Patient data were analyzed using Chi-Square tests and outcomes were analyzed using independent samples t tests and Mann-Whitney U tests. There were 136 primary and 82 reoperative fundoplications. Prior to surgery, GERD-HRQL scores were similar for primary and reoperative patients. Both groups experienced significant improvement in GERD-related quality of life at 2years, although this improvement was greater in primary patients (8.7 ± 7.8 primary vs. 14.3 ± 13.6 reoperative, p = 0.02). Operative time and length of stay were longer following reoperative cases. The rate of moderate to severe 30-day complications requiring radiologic, endoscopic, or surgical intervention was similar (2.9% primary vs. 1.2% reoperative, p = 0.65). Patients who undergo reoperative fundoplication experience a significant improvement in their GERD-related symptoms, although not to the degree seen in primary antireflux surgery patients. Perioperative morbidity rates following reoperative and primary procedures can be similar in the hands of an experienced surgeon.

Hospital Volume of Antireflux Surgery in Relation to Endoscopic and Surgical Re-interventions.

To test the hypothesis that higher hospital volume decreases endoscopic and surgical re-intervention rates after antireflux surgery. Antireflux surgery for gastro-esophageal reflux disease is followed by varying rates of re-interventions. Whether hospital volume influences re-intervention rates is uncertain. This population-based cohort study used nationwide data from Denmark, Finland, and Sweden for patients having undergone primary antireflux surgery. Hospitals were divided into tertiles based upon annual volume, that is, 3 equal-sized groups. The outcomes were 30-day surgical re-intervention, endoscopic re-intervention, and secondary antireflux surgery. Multivariable Cox regression provided hazard ratios (HRs) with 95% confidence intervals (CIs) for risk of the first outcome occurrence. Incidence rate ratios were calculated to count all outcome occurrences. All risk estimates were adjusted for age, sex, comorbidity, type of antireflux surgery, year of surgery, and country. Among 33,060 patients and a median follow-up of 12 years after antireflux surgery, the frequencies of 30-day re-intervention, endoscopic re-intervention, and secondary antireflux surgery were 1.2%, 4.6%, and 7.0%, respectively. When comparing the highest with the lowest tertiles, higher hospital volume did not decrease HRs of 30-day re-intervention (adjusted HR = 1.14, 95% CI 0.73-1.77), endoscopic re-intervention (HR = 1.21, 95% CI 0.96-1.51), or secondary antireflux surgery (HR = 1.28, 95% CI 1.05-1.54), but rather increased point estimates. The incidence rate ratios showed similar patterns. Higher hospital volume of primary antireflux surgery may not decrease risk of endoscopic or surgical re-intervention, suggesting that centralization will not decrease rates of postoperative complications or recurrence of gastro-esophageal reflux disease.

Mo1013 - A Case for the Robot: Comparing Outcomes of Robotic Reoperative and Primary Antireflux Surgery

Mo1013 - A Case for the Robot: Comparing Outcomes of Robotic Reoperative and Primary Antireflux Surgery

Remedial bypass or antrectomy and Roux-en-Y after failed fundoplication

Excellent outcomes have been reported with primary antireflux surgery; however, some patients require reoperation. Of the patients who undergo reoperation, a select few are at higher risk for poor outcomes after redo fundoplication. The high-risk group includes patients who are morbidly obese; those with a short esophagus, poor esophageal motility, or patients who have undergone; multiple (i.e., more than 2) reoperative procedures; and those with delayed gastric emptying. These patients are better served with Roux-en-Y (RNY) gastrojejunostomy, with or without gastrectomy. In this article, we summarize our approach for reoperative intervention after antireflux surgery has failed, and discuss criteria for patient selection, operative technique, and outcomes of RNY reconstruction as a remedial antireflux procedure.

Collis gastroplasty: why, when and how?

Collis gastroplasty was originally designed to deal with the increasing incidence of short esophagus (SE) associated with the new epidemic of gastroesophageal reflux disease (GERD) and hiatal hernias. In following years, a fundoplication was added to the procedure in an attempt to correct the underlying cause of the disease. Nowadays Collis gastroplasty with fundoplication is the standard treatment for patients in whom, even after an extensive surgical dissection of the distal esophagus, the gastroesophageal junction (GEJ) cannot be brought at least 2.5 cm below the diaphragmatic hiatus without tension. The real incidence of SE is controversial in the era of laparoscopic fundoplication, with some groups proposing that all short esophagi can be solved with adequate mediastinal dissection of the esophagus prior to fundoplication, and others advocating frequent use of the Collis. Still others have tried to identify predictive factors linked to the presence of a true SE. However, studies suggest that a significant percentage of failures of primary antireflux surgery might be due to axial tension on the repair from intrinsic shortening of the esophagus that was not properly addressed. With the advent of the laparoscopic era new tools and new approaches were described to asses and to treat this condition. We describe both thoracoscopic/laparoscopic and totally laparoscopic techniques for minimally invasive Collis gastroplasty. While symptomatic results are good, the procedure is non-physiologic and many patients have esophagitis from ectopic gastric mucosa. While the true incidence of SE is unknown, what is undeniable is that chronic reflux disease can lead to foreshortening of the esophagus and, although in the proton pump inhibitor (PPI) era the presence of a SE is a relatively rare finding, the foregut surgeon must be prepared to identify and treat this condition.

Primary and Redo Antireflux Surgery: Outcomes and Lessons Learned

IntroductionSome patients require one or more reoperative interventions after undergoing primary antireflux surgery (ARS). We compared outcomes after primary and reoperative ARS. MethodsWe queried a prospectively maintained database to identify patients who underwent ARS from September 23, 2003 to May 28, 2016. Patients were categorized into four groups: A (primary ARS), B (first reoperative ARS), C (second reoperative ARS), or D (≥ third reoperative ARS). Patients completed follow-up foregut symptom surveys and satisfaction questionnaires at regular intervals. ResultsIn total, 940 patients were studied (A: n = 545, B: n = 302, C: n = 80, D: n = 13). Age, sex, and BMI were comparable across groups. Heartburn was the most common preoperative symptom in A, whereas dysphagia was more common in B–D. Open approach, mean operative time, and mean blood loss increased from A to D (P < 0.05), as did need for Roux-en-Y reconstruction. Vagal injury (2–19–33–54%; P < 0.05), visceral perforation (2–20–36–23%; P < 0.05), postoperative leak (0.2–2–6–8%; P < 0.05 A vs. all), and morbidity (2–10–14–39%; P < 0.05) also increased from A to D. At mean follow-up of 36 months, the proportion of patients who reported no significant symptoms, excellent satisfaction, and likeliness to recommend this surgery to a friend progressively declined with each successive reintervention (P < 0.05). ConclusionsComplications and patient-reported outcomes worsen with each reoperative ARS.